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A Percutaneous Treatment Algorithm forCrossing Coronary Chronic Total OcclusionsEmmanouil S. Brilakis, MD, PHD,* J. Aaron Grantham, MD,† Stéphane Rinfret, MD, SM,‡R. Michael Wyman, MD,§ M. Nicholas Burke, MD,� Dimitri Karmpaliotis, MD,¶Nicholas Lembo, MD,¶ Ashish Pershad, MD,# David E. Kandzari, MD,¶ Christopher E. Buller, MD,**Tony DeMartini, MD,†† William L. Lombardi, MD,‡‡ Craig A. Thompson, MD, MMSC§§Dallas, Texas; Kansas City, Missouri; Torrance, California; Minneapolis, Minnesota; Atlanta, Georgia;Phoenix, Arizona; Quebec City, Quebec and Toronto, Ontario, Canada; Springfield, Illinois;
Bellingham, Washington; and New Haven, Connecticut
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JACC: CARDIOVASCULARINTERVENTIONS CME

This article has been selected as this issue’s CME activity,available online at http://interventions.onlinejacc.org/ byselecting the CME tab on the top navigation bar.Accreditation and Designation StatementThe American College of Cardiology Foundation(ACCF) is accredited by the Accreditation Councilfor Continuing Medical Education (ACCME) toprovide continuing medical education for physicians.

The ACCF designates this Journal-based CME ac-tivity for a maximum of 1 AMA PRA Category 1 Cred-t(s)™. Physicians should only claim credit commensurateith the extent of their participation in the activity.ethod of Participation and Receipt ofME Certificateo obtain credit for this CME activity, you must:. Be an ACC member or JACC: Cardiovascular

Interventions subscriber.. Carefully read the CME-designated article avail-

able online and in this issue of the journal.. Answer the post-test questions. At least 2 out of

the 3 questions provided must be answered cor-rectly to obtain CME credit.

. Complete a brief evaluation.

. Claim your CME credit and receive your certif-icate electronically by following the instructionsgiven at the conclusion of the activity.

ME Objective for This Article: At the end ofhis activity the reader would be able to: 1) discuss thetrengths and limitations of different wire crossing strate-ies for coronary chronic total occlusions; 2) determine anptimal procedural planning strategy for crossing coronaryhronic total occlusions by evaluating four key angio-raphic parameters; and 3) discuss the role and optimalse of various types of equipment that are available foracilitating crossing of coronary chronic total occlusions.ME Editor Disclosure: JACC: Cardiovascular

nterventions CME Editor Habib Samady, MB,hB, FACC, has research grants from the Wallace. Coulter Foundation, Volcano Corp., St. Jude Med-

cal, Forrest Pharmaceuticals Inc., and Pfizer Inc. E

uthor Disclosure: Dr. Brilakis has received speakeronoraria from St. Jude Medical and Terumo; researchupport from Abbott Vascular and InfraReDx; and hispouse is an employee of Medtronic. Dr. Grantham haseceived grants and honoraria from Abbott Vascular,ridgePoint Medical, and Vascular Solutions, all paidirectly to Saint Luke’s Hospital Foundation. Dr. Rinfretas received honoraria for proctorship from Abbott Vas-ular and BridgePoint Medical and honoraria for confer-nce from Terumo and BridgePoint Medical. Dr. Wy-an is a consultant/honoraria from Abbott Vascular,ridgePoint Medical, Terumo, and Boston Scientific;nd has equity in BridgePoint Medical. Dr. Burke is aonsultant for BridgePoint Medical and Terumo Medi-al. Dr. Karmpaliotis is on the speaker’s bureau of Abbottascular and Medtronic; and is a consultant for Bridge-oint Medical. Dr. Lembo is on the speaker’s bureau ofedtronic; he is on the advisory board of Abbott Vascu-

ar and Medtronic; and he is a proctor for BridgePointedical. Dr. Pershad has received speaker honoraria fromedtronic and Abbott Vascular; and consulting fees from

ridgePoint Medical. Dr. Kandzari’s institution (Pied-ont Heart Institute) has received educational grants

rom BridgePoint Medical; and he has received research/rant support from and is a consultant for Abbott Vas-ular, Medtronic CardioVascular, and Boston Scientific.r. Buller is a consultant for Abbott Vascular andstraZeneca. Dr. DeMartini is a consultant for and on

he speaker’s bureau of Abbott Vascular. Dr. Lombardi isconsultant for Abbott Vascular, BridgePoint Medical,

nd Medtronic; has received speaker honoraria frombbott Vascular, Medtronic, Boston Scientific, anderumo (all funds paid to his institution - PeaceHealth);

nd has equity in BridgePoint Medical. Dr. Thompson isconsultant for Abbott Vascular, BridgePoint Medical,erumo, and Volcano; and has equity in BridgePointedical.

edium of Participation: Print (article only);nline (article and quiz).

ME Term of Approval:ssue Date: April 2012
xpiration Date: March 31, 2013
http://interventions.onlinejacc.org/

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A P R I L 2 0 1 2 : 3 6 7 – 7 9

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Algorithm for CTO Crossing

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A Percutaneous Treatment Algorithm for Crossing CoronaryChronic Total Occlusions

Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challeng-

ing lesion group to treat. Patients with CTOs are frequently left unrevascularized due to perceptions of high failure rates and

technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North

American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate

seamless transition between antegrade wire–based, antegrade dissection re-entry–based, and retrograde (wire or dissection

re-entry) techniques, the “hybrid” interventional strategy. After dual coronary injection is performed, 4 angiographic parameters

are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) le-

sion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collat-

erals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical

approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the proce-

dure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and

effectiveness. (J Am Coll Cardiol Intv 2012;5:367–79) © 2012 by the American College of Cardiology Foundation

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Percutaneous coronary intervention (PCI) of coronarychronic total occlusions (CTOs) has historically been lim-ited by technical success rates of �50% to 70%, despitebeing performed in highly selected cases (1–4). In thecurrent era, however, operators and programs with higherCTO PCI–specific experience and modern techniques andtechnologies can consistently achieve technical success ratesof �80% in a more unselected and complex population ofCTO patients, as has been reported in Europe (5), Japan(6), the United States (7), and Canada (8). Although thereare multiple reports on techniques that can result insuccessful CTO PCI, there is little published informationon how these techniques can be used together, as part ofa comprehensive procedural strategy. The goal of thepresent report is to propose an algorithmic approach toCTO PCI, in an attempt to demystify the field and createcommon ground among operators who are currently

From the *VA North Texas Healthcare System and UT Southwestern MedicalCenter, Dallas, Texas; †Mid America Heart Institute, Kansas City, Missouri;‡Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada;§Torrance Memorial Medical Center, Torrance, California; �Minneapolis HeartInstitute and Foundation, Minneapolis, Minnesota; ¶Piedmont Heart Institute,Atlanta, Georgia; #Banner Good Samaritan Medical Center, Phoenix, Arizona;**University of Toronto, Toronto, Canada; ††Prairie Cardiovascular, Springfield,Illinois; ‡‡PeaceHealth Cardiology, Bellingham, Washington; and the §§YaleUniversity School of Medicine, New Haven, Connecticut. Dr. Brilakis has receivedspeaker honoraria from St. Jude Medical and Terumo; research support from AbbottVascular and InfraReDx; and his spouse is an employee of Medtronic. Dr. Granthamhas received grants and honoraria from Abbott Vascular, BridgePoint Medical, andVascular Solutions, all paid directly to Saint Luke’s Hospital Foundation. Dr. Rinfrethas received honoraria for proctorship from Abbott Vascular and BridgePointMedical and honoraria for conference from Terumo and BridgePoint Medical. Dr.Wyman is a consultant/honoraria from Abbott Vascular, BridgePoint Medical,
Terumo, and Boston Scientific; and has equity in BridgePoint Medical. Dr. Burke isa consultant for BridgePoint Medical and Terumo Medical. Dr. Karmpaliotis is on 2
performing, or are interested in developing a CTO PCIprogram. The approach presented herein is based on theexpert opinion of 13 high-volume North American CTOoperators. The purpose of this proposed algorithm is toprovide a consistent framework that can be used toevaluate patients considered for CTO PCI and provide areproducible and teachable method to expand a base ofinterventionalists that perform safe, effective, and effi-cient CTO PCI.

Fundamentals and the Learning Curve

The current paper presupposes that experience with therequisite techniques and technologies has been establishedbefore applying the following algorithms. During the learn-ing phase for CTO operators and CTO programs, theseexperiences may be more compartmentalized to certain

he speaker’s bureau of Abbott Vascular and Medtronic; and is a consultant forridgePoint Medical. Dr. Lembo is on the speaker’s bureau of Medtronic; he is on thedvisory board of Abbott Vascular and Medtronic; and he is a proctor for BridgePoint

edical. Dr. Pershad has received speaker honoraria from Medtronic and Abbottascular; and consulting fees from BridgePoint Medical. Dr. Kandzari’s institution

Piedmont Heart Institute) has received educational grants from BridgePoint Medical;nd he has received research/grant support from and is a consultant for Abbott Vascular,

edtronic CardioVascular, and Boston Scientific. Dr. Buller is a consultant for Abbottascular and AstraZeneca. Dr. DeMartini is a consultant for and on the speaker’s bureauf Abbott Vascular. Dr. Lombardi is a consultant for Abbott Vascular, BridgePointedical, and Medtronic; has received speaker honoraria from Abbott Vascular,edtronic, Boston Scientific, and Terumo (all funds paid to his institution - Peace-ealth); and has equity in BridgePoint Medical. Dr. Thompson is a consultant for Abbottascular, BridgePoint Medical, Terumo, and Volcano; and has equity in BridgePointedical.

anuscript received December 1, 2011; revised manuscript received February 7,
012, accepted February 9, 2012.

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A P R I L 2 0 1 2 : 3 6 7 – 7 9 Algorithm for CTO Crossing

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strategies, as there is often safety and technical equipoisebetween approaches. We recognize that it is not reasonableto propose algorithms that weigh toward methods that havenot been accessible or employed by the emerging operators.Lifetime non-CTO PCI experience, although helpful, doesnot immediately translate to better CTO PCI techniques, asthese techniques, wires, and devices are often employed in amanner that is counterintuitive to the standard PCI proce-dure. To this end, we strongly recommend local proctoringprogram and attendance at local and national CTO focusedmeetings to develop the didactic and clinical skill setsrequired for advanced CTO PCI. Although this papercannot alleviate the need for proper proctorship of newCTO operators, it summarizes information often transmit-ted in teaching sessions in an organized manner. As the CTOPCI operator becomes more confident with wire selection,shaping, manipulation, device utilization, and advanced tech-niques (e.g., retrograde and antegrade re-entry techniques), areasonable transition can occur to employ the following algo-rithms to optimize the CTO procedures in terms of efficiency,safety, and effectiveness. The learning curve and applications ofthe algorithms, however, need not be mutually exclusive in theproctored environment because the patient’s anatomy willdictate strategies.

Indications for CTO PCI

A detailed, in-depth clinical assessment is critical beforeproceeding with CTO PCI. CTO PCI should only beperformed if it carries a favorable risk/benefit ratio. CTOPCI can provide angina relief (9), improve exercise tolerance(10) and left ventricular function (11), improve tolerance ofa future acute coronary syndrome (12), reduce the need forcoronary artery bypass graft surgery (13), and possibly improvesurvival if successful (especially for PCI of left anterior de-scending artery CTOs) (2,14). Moreover, CTO PCI carriessimilar risk to non-CTO PCI (1). As with any type of coronaryrevascularization, CTO PCI will mostly benefit patients whohave angina refractory to optimal medical management (15)and those with large ischemic burden.

Pre-Procedure Angiographic Review, ArterialAccess, and the Role of Dual SelectiveAngiography for CTO PCI

Careful study of the target CTO lesion cannot be overem-phasized: 20 min of pre-procedure review of the angiogramis often required to fully understand the CTO anatomy andcollateral circulation. We discourage routine “ad hoc” CTOPCI because pre-planning facilitates a thoughtful proce-dural approach and estimation of the risk–benefit ratio inthis complex lesion/patient subset. Understanding the vesselcourse and the presence, quality, and location of collateral
vessels can allow rapid adjustments and change of strategies
during the procedure and maximizes the likelihood ofprocedural success.

In the current report, we advocate a routine 2 guidecatheter strategy, with a shortened (�90 cm long) catheterin the retrograde vessel to allow for seamless, efficienttransition between antegrade and retrograde techniques ineligible patients. Long (35 to 45 cm) sheaths and large-boreguide catheters (7- to 8-F) are preferred for providingadditional support and options, although experienced tran-sradial operators can successfully perform CTO usingsmaller 6-F catheters (8). Dual arterial access is commonlyused (bifemoral, biradial, femoral–radial). Alternative meth-ods to augment guide catheter support include “mother andchild” extensions, such as the GuideLiner catheter (VascularSolutions, Minneapolis, Minnesota) (16) and variousballoon anchoring techniques (17–19).

Dual injection is critical for performing CTO PCI andshould be performed in every case where contralateralcollaterals exist (20). Nonsimultaneous, single-catheter in-jection frequently provides suboptimal visualization of theCTO segment and limited abil-ity to assess the proximal anddistal caps, and distal vessel be-yond the CTO, due to collateralcompetitive flow. In addition,single-catheter antegrade injectionduring dissection/re-entry tech-niques may result in hydraulic en-largement of the subintimal spaceand reduce the chances of successfulre-entry. Filling the collateral bedwith dual injection reduces non-contrast-containing competitiveflow and provides optimal visualiza-tion of the CTO vessel. Furthermore, the collateral flow directionand strength of flow can shift from 1 source to another during thecourse of a procedure, likely due to collateral compromise as wellas potential activation of vasoactive substances during intervention.

Dual injection is performed through selective coronaryangiography from the CTO PCI target vessel and throughanother vessel (the contralateral coronary artery or a bypassgraft) that provides collaterals to the distal target vessel.Dual injection is crucial for determining the lesion lengthand the size and location of the distal target vessel, evalu-ating whether there is a significant bifurcation at the distalcap, and for deciding on the optimal CTO PCI strategy(20). Occasionally, dual injection will reveal that the “CTO”may actually not be a total occlusion, but rather a “func-tional” occlusion with a central patent microchannel. Dualinjection can reveal the presence, size, and tortuosity ofcollateral vessels and help determine whether a retrogradeapproach is feasible. Dual injection is also critical forclarifying the location of the angioplasty wire or other

Abbreviationsand Acronyms

CART � controlledantegrade and retrogradetracking

CTO � chronic totalocclusion

LaST � limited antegradesubintimal tracking

OTW � over the wire

PCI � percutaneouscoronary intervention

RAO � right anterior oblique

equipment during CTO crossing a
ttempts.


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Dual injection is best performed at low magnification,with prolonged imaging exposure, and without table pan-ning, to allow for optimal delineation of the CTO segmentand collateral vessel location and course. To minimizeradiation exposure, the donor vessel (vessel that supplies theterritory distal to the CTO) is injected first, followed byinjection of the occluded vessel (20). Bridging collaterals areimportant to recognize and avoid during both antegrade andretrograde crossing attempts to minimize the risk of vesselperforation, especially when advancing microcatheters andballoons. Septal collaterals are best visualized from a rightanterior oblique (RAO) cranial view, or straight RAO view,whether the donor vessel is the posterior descending coro-nary artery or the left anterior descending coronary artery.Epicardial collaterals often need tailored views to assesstheir course, as they are often from diagonal, left circumflex,and right coronary posterolateral territories; the left anterioroblique and RAO cranial views are often the best to imagedistal lateral wall collaterals between obtuse marginal arter-ies and posterolateral arteries and diagonal to diagonal/obtuse marginal connections; and the RAO and anteropos-terior caudal views are preferred for collaterals connectingthe more proximal obtuse marginal arteries and those arisingin the atrioventricular groove between the circumflex andright coronary arteries.

In patients with only ipsilateral collaterals, dual arterialaccess and dual injection may not be required, although insome cases, contralateral collaterals may appear if ipsilateralcollaterals are compromised during CTO crossing attempts.Moreover, 2 guide catheters may be required if retrogradeCTO crossing is performed via ipsilateral collaterals: 1 guidecatheter is used to advance the retrograde guidewire, and asecond one is used for externalizing the retrograde guide-wire and/or antegrade wiring. Engagement of the targetcoronary artery is alternating between the antegrade and theretrograde guide catheter in a “ping-pong” fashion, enablinglesion crossing and equipment delivery (21).

The “Base of Operations”

The first goal of the proposed algorithm is to safely andefficiently establish guidewire and microcatheter position inthe lesion segment known as the “base of operations.” Thepurpose is to spend procedure time, radiation, and contrastfocused on final recanalization of a short, isolated segment.The base of operations is typically at or near the distal capfor the antegrade direction and at or near the proximal capfor retrograde direction procedures. It is important to realizethat this effective working segment may need to be shiftedto a different location within the vessel, for example, beyondthe distal cap for re-entry, or elsewhere in the CTOsegment for controlled antegrade retrograde tracking(CART), reverse CART, and limited antegrade subintimal
tracking (LaST), if refractory situations occur. The flexibil-
ity in the base of operations as well as strategic changes arecritical to the application of the “hybrid” CTO PCI tech-nique. We define the “hybrid” approach to CTO PCI, asthe approach that focuses on opening the occluded vessel,using all feasible techniques (antegrade, retrograde, true-to-true lumen crossing or re-entry) in the most safe, effective,and efficient way.

Anatomy Dictates Initial Strategy

In the proposed algorithm, 4 angiographic characteristicsdetermine the initial procedural approach in patients havingCTO PCI:

1. Proximal cap location and morphology. This charac-teristic refers to the ability to unambiguously localizethe entry point to the CTO lesion by angiographyand/or intravascular ultrasound and to be able toproperly engage the lesion considering bridging col-laterals, as well as side branches, with appropriatewire/device support (which can be complicated inostial locations).

2. Lesion length. Lesions are dichotomized to �20versus �20 mm. CTO PCI on lesions �20 mm inlength tends to have lower success rates and longerprocedure times using standard antegrade wire escala-tion (22), and may be best approached with earlyadoption of alternative techniques, such as primaryantegrade dissection and re-entry, or retrograde tech-niques. As noted in the previous text, in most cases,this characteristic can only be accurately assessed byusing dual injections.

3. Target coronary vessel at the distal cap. This refers tothe size of the lumen, to the presence of significantside branches, to the relative angiographic health ofthe vessel at the reconstitution point, and importantly,to the ability to adequately angiographically visualizethis segment.

4. Size and suitability of collateral circulation for retro-grade techniques. Optimal collateral vessels for retro-grade CTO PCI are sourced from a healthy (orrepaired) donor vessel, can be easily accessed withwires and microcatheters, have minimal tortuosity, arenot the only source of flow to the CTO segment (withrisk for intraprocedural ischemia), and enter the CTOvessel well beyond the distal cap. More favorablecollateral circulation characteristics lower the barriersto utilizing retrograde techniques as an initial strategyor early crossover strategy.

Device Platforms to Support CTO PCI

We favor a selected device portfolio to support coronary
CTO PCI to streamline decision trees, develop operator



371

device-specific expertise, and manage catheterization labo-ratory and procedure costs. We do recognize the utility ofother wires and devices, as well as novel technologiescurrently in development, but the following support most ofour current PCI procedures:

Four-wire strategy:

1. A hydrophilic and/or polymer-jacket 0.014-inchguidewire, low gram-force, with tapered 0.009-inchtip, for antegrade microchannel or soft tissue probingand also for knuckle techniques. Examples include theFielder XT wire (Asahi Intecc, Nagoya, Japan) andRunthrough taper wire (Terumo Corporation, Tokyo,Japan).

2. A nontapered, polymer-jacket hydrophilic 0.014-inchguidewire for collateral channel crossing in retrogradeprocedures. Examples include the Fielder FC wire(Asahi Intecc) and Pilot 50 wire (Abbott Vascular,Santa Clara, California).

3. A moderately high–gram-force (4 to 6 g), polymer-jacket, nontapered 0.014-inch guidewire for complexlesion crossing, long lesions, knuckle technique, anddissection/re-entry, such as the Pilot 200 guidewire(Abbott Vascular). This wire is particularly useful forlong lesions and complex lesions, and performs well invery tortuous segments with an ambiguous course.

4. A high–gram-force 0.014-inch guidewire, with atapered 0.009-inch nonjacketed tip for penetrationtechniques, cap puncture, complex lesion crossing, andlumen re-entry techniques. An example is the Confi-anza Pro 12 wire (Asahi Intecc). This wire and similardevices are best used when the vessel pathway andlocation target coronary segment are well understood.

Guidewire selection and utilization is independent ofwhether an antegrade or retrograde approach is used. Mostwires should be shaped by inserting the wire through anintroducer tool and placing a shallow 30° to 45° bend nomore than 1 mm from the tip. Occasionally, a secondarybend is required to allow for proper orientation in the vessel.Finally, a more acute bend, 2 to 3 mm from the tip, may berequired for high–gram-force wires when wire-based lumenre-entry is contemplated. Coronary guidewires commonlyused for CTO PCI are listed in Table 1.

Microcatheters:

1. Corsair microcatheter (Asahi Intecc). This is a 2.7-Fcatheter with a lubricious outer coating, a bidirectionalwire braiding for torque transmission, and an innerpolymer lumen with soft tip for optimal wire control.At present, this device is unique in providing a reliableplatform to cross collateral channels and provides theprimary basis for conventional retrograde procedures(23). This microcatheter can also be used in the
antegrade direction for wire support and exchange as
well as lesion crossing, although we usually employsmaller outer diameter microcatheters for these pur-poses. The Corsair catheter is advanced by rotation ineither direction. The Corsair should not be over-rotated (�10 consecutive turns without release) asover-rotation could cause catheter kinking. Contrastcan be injected through the Corsair for distal vesselvisualization, but the catheter should subsequently beflushed to minimize the risk for guidewire “stickiness”and entrapment.

2. Small outer diameter, over-the-wire (OTW) micro-catheters. Examples include the Finecross (TerumoCorporation) and Quick-Cross (Spectranetics Corpo-ration, Colorado Springs, Colorado) catheter for wiresupport and exchange.

3. Small OTW balloons for wire support and exchange.4. Tornus microcatheter (Asahi Intecc). This is a braided-

wire mesh OTW microcatheter with left-handed threadallowing for channel preparation and lesion crossing inresistant occlusions. The Tornus is advanced using coun-terclockwise rotation and removed using clockwise rota-tion. A coronary guidewire should remain within theTornus inner lumen during manipulations, and over-rotation should be avoided to minimize the risk ofkinking. Contrast injections should not be performedthrough the Tornus, as the contrast escapes through thewire braid and does not reach the catheter tip.

Lesion crossing and lumen re-entry technologies:

1. CrossBoss catheter (BridgePoint Medical, Plymouth,Minnesota). This is a metal OTW microcatheter witha rounded tip to prevent vessel exit (24). This device isrotated rapidly, in either direction, using a “fast spin”technique (rapid rotation of the catheter using bothhands) and can advance forward through a CTOwithout the wire in the lead. If a subintimal/subad-ventitial position is obtained beside the true lumen,re-entry is performed.

2. Stingray balloon and Stingray guidewire systems(BridgePoint Medical). The Stingray balloon is a1-mm flat balloon with 3 exit ports connected to thesame guidewire lumen (24). The distal exit port is usedto place the balloon in position. The other 2 ports are180° opposed, so that when inflated, 1 is oriented to thelumen and the other toward the adventitia. Using fluo-roscopy for directional orientation, the Stingray guide-wire (a 0.014-inch high–gram-force guidewire with adistal tapered “probe” to grab tissue) is used to penetratethe distal true lumen and gain guidewire position.

Safety devices: CTO PCI catheterization laboratoriesshould be equipped with a selection of covered stents (25),embolization coils and delivery systems, pericardiocentesis
trays to manage perforation (26), and thrombectomy devices

s coron


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to manage thrombotic complications. Hemodynamic sup-port system availability is a prerequisite as well.

Initial Strategy—Algorithm

All cases are planned as previously discussed in anticipa-tion of both antegrade and retrograde approaches (theso-called “hybrid” procedure). The initial directional strategyof antegrade or retrograde is dependent on the anatomyconfirmed by dual angiography as described with 4 primaryvariables considered: 1) ability to identify and safely andeffectively engage the proximal cap; 2) lesion length; 3) signif-icant branches, size and quality of the target at the distal cap;and 4) suitability and anticipated ease of retrograde “interven-tional” collaterals. The goal is to safely and efficiently recanalizethe ischemic bed and provide a “quality result” while maintain-ing patency of pertinent side branches and outflow vessels.

The combinations of these simple factors can determinethe primary strategy for most procedures (Fig. 1) and

Table 1. Description of Coronary Guidewires Commonly Used in CTO PCI

Wire Category Tip Style Commercial N

Polymer covered Tapered Fielder XT*

Straight (nontapered),low tip stiffness

Fielder FC*Whisper LS, MS, ESPilot 50Choice PT Floppy

Straight (nontapered),high tip stiffness

Pilot 150/200*Crosswire NTPT Graphix IntermediatePT2 Moderate SupportShinobiShinobi Plus

Open coil (nopolymer jacket)

Straight, low tip stiffness SION (hydrophilic)

Tapered, low tip stiffness Cross-it 100XT (0.010-inch)Runthrough NS tapered (0.00

Tapered, high tip stiffness,hydrophilic coating

Confianza Pro 9, 12* (0.009-inPROGRESS 140T, 200T (0.010Persuader 9 (0.011-inch)ProVia 9, 12 (0.009-inch)

Straight tip, high tipstiffness

MiracleBros 3, 4.5, 6MiracleBros 12PROGRESS 40, 80, 120Persuader 3 and 6 (hydrophiProvia 3, 6 (hydrophilic and -

Tapered, high tip stiffness,hydrophobic coating

Confianza 9 (hydrophobic)Persuader 9 (hydrophobic)ProVia 9, 12 (hydrophobic)

Externalization wires Viper*RG3RotaWire Floppy and Extra S

*Most commonly used guidewires.

CTO � chronic total occlusion; LaST � limited antegrade subintimal tracking; PCI � percutaneou

identify subsequent secondary and tertiary bailout tech-

niques, should the primary strategy fail. In summary, shortlesions (�20 mm) with clearly identified proximal caps andgood distal vessel targets are initially approached with anantegrade wire escalation strategy. A lesion length �20 mmhas been identified as a predictor of rapid CTO crossing inthe Japan CTO Registry (Multicenter CTO Registry inJapan) (22). Longer and complex lesions with clearly iden-tified proximal caps and distal target favor a primarydissection re-entry approach. Other complex lesions withpoor distal targets or ambiguous access points may favor aninitial retrograde approach. The threshold for dissection/re-entry or retrograde technique as an initial strategy is loweredin reattempt procedures.

General Considerations for Strategic Changesand Procedural Efficiency

The new, hybrid CTO PCI strategy places emphasis, notonly on procedural success, but also on procedural efficiency,

Tip Stiffness Manufacturer Properties

1.2 g Asahi Intecc Frontline wire for antegradecrossing. Can also beused for creating knucklewire and for retrogradecrossing

1.6 g0.8, 1.0, 1.2 g1.5 g2.1 g

Asahi InteccAbbott VascularAbbott VascularBoston Scientific

Used to cross throughcollateral vessels duringthe retrograde approach

2.7 g/4.1 g7.7 g1.7 g2.9 g7.0 g6.8 g

Abbott VascularTerumoBoston ScientificBoston ScientificCordisCordis

Antegrade crossing,especially when thecourse of the occludedvessel is unclear. Alsouseful for knuckle wireformation and for re-entry into true lumenduring LaST technique

0.8 Asahi Intecc

)1.7 g1.0 g

Abbott VascularTerumo

0.009-inch)9.3, 12.4 g12.5, 13.3 g9.1 g11.8, 13.5 g

Asahi InteccAbbott VascularMedtronicMedtronic

Antegrade crossing whenvessel course known

-phobic))

3.9, 4.4, 8.8 g13.0 g5.5, 9.7, 13.9 g5.1, 8.0 g8.3, 9.1 g

Asahi InteccAsahi InteccAbbott VascularMedtronicMedtronic

Antegrade crossing whenvessel course is known

8.6 g9.1 g11.8, 13.5 g

Asahi InteccMedtronicMedtronic

Antegrade crossing whenvessel course is known

3.6 g CSIAsahi InteccBoston Scientific

335 cm in length330 cm in length325 cm in length

ary intervention.

ame

8-inch

ch)5-inch,

lic andphobic

upport

aiming to successfully recanalize the CTO in the shortest

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possible period and using the least amount of radiation,contrast, and equipment. The optimal techniques and tech-nologies are applied during the specific time of the proce-dure when they are most likely to be effective. The practicalramifications of this method are that changes of strategyshould occur very early, and often cycle rapidly, to maximizethe likelihood of early successful crossing. Far too often inconventional CTO PCI, standard strategies are pursuedbeyond the point of diminishing return, and bailout tech-niques are applied when their utility is greatly reduced. Anintended by-product of the hybrid CTO PCI approach is toreduce procedure time, patient and staff radiation exposure,and contrast utilization. Although there are no universallyaccepted time limits for each of the steps described in thealgorithm (Fig. 1), the recommendation is to stop pursuinga technique that has not resulted in any significant progressduring a reasonable period. At this point, which is soonerthan traditional PCI, a different technique (such as newguidewire, new microcatheter, the retrograde approach, andso on) should be tried. Generally, no more than 5 to 10 minshould be spent in a stagnant mode without minor or majortechnique adjustments being made.

Careful attention to fluoroscopy use throughout the caseis important to minimize the risks associated with radiationexposure. Use of �5-Gy air kerma dose can lead to skininjury, and �10 Gy significantly increase this possibility,herefore the procedure should usually be stopped beforexceeding 10 Gy, unless lesion crossing has occurred andittle extra time is needed to complete the procedure (27).

Figure 1. Algorithm for Crossing CTOs

The algorithm starts with dual coronary injection (box 1) to allow assessmentgrade (boxes 3 to 5) or primary retrograde (box 6) strategy. Strategy changeocclusion; LaST � limited antegrade subintimal tracking.

Minimizing fluoroscopy time, routine utilization of non-

magnified viewing, decreasing frame rate, coning, fluoros-copy storage (in lieu of cine acquisition), and image inten-sifier positional adjustment/rotation can limit skin exposureto radiation at each entry point (27). Radiation dosing,monitored closely during the procedure, is a pre-eminentfactor in strategic intraprocedural strategy changes in addi-tion to case time and lack of progress.

Unfractionated heparin is the anticoagulation of choicefor CTO PCI, as it can be reversed in case of significantperforation. At the present time, we strongly discourage theuse of bivalirudin, low-molecular-weight heparin, or glyco-protein IIb/IIIa inhibitors. Finally, the contrast load admin-istered should be monitored closely during the procedure,and pre-procedural hydration is encouraged.

Hybrid Techniques

The technical executions within the hybrid CTO PCIprocedure are wire escalation (similar in either antegrade orretrograde direction) and dissection/re-entry (Stingray de-vice or wire [the LaST technique] in antegrade directionand CART or reverse CART in retrograde direction).

Wire Escalation

As noted in Figure 1, this is the initial strategy of choice ina �20-mm CTO with reasonably definable proximal capand distal target. The initial wire to probe the CTO istypically a low–gram-force, polymer-jacket wire, unless theproximal cap is clearly blunt, calcified, or ambiguous. We

eral angiographic parameters (box 2) and allow selection of a primary ante-ade (box 7), depending on the progress of the case. CTO � chronic total

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Fielder XT, Asahi Intecc) and nontapered in the retrogradedirection (as this wire is available having been used to crossthe collateral vessels). The lesion is probed with a softsliding technique, with soft drilling and emphasis in keepingthe tip free and with appropriate shape on fluoroscopy. Ifthe wire buckles, the OTW support catheter is advanced tosupport column strength at the tip. Probing is againperformed. If the wire demonstrates lack of progress, goesoffline, or buckles, it is determined to be ineffective and wireexchange is performed. In our experience, this series ofmaneuvers can be accomplished within a few minutes and,therefore, initial probing is not intended to be an extensive,time-consuming effort. The subsequent wire is determinedby lesion characteristics. If the crossing distance is long,uncertain, or tortuous, we favor a moderately high–gram-force, nontapered, polymer-jacket wire, such as the Pilot200 (Abbott Vascular). This platform is optimal for trackingthe vessel structure and rarely exits the wall of the CTOsegment. If the lesion distance is short and its course wellunderstood, a stiff, tapered penetration wire (such as theConfianza Pro 12, Asahi Intecc) is chosen, employing afocused, directional penetration technique. Each of thesewire platforms will serve as the subsequent bailout for theother. If the wires fail to progress (Fig. 2, Online Videos 1,2, 3, 4, and 5), or enter the subintimal space (remainingwithin the vessel wall), conversion to dissection re-entrytechniques is performed.

Dissection Re-Entry Techniques

Antegrade dissection. Antegrade dissection occurs when auidewire or crossing catheter advances antegradely withinhe subintimal space (inside the vessel wall but outside theimits of what formerly was the true lumen). This can bechieved by using a CrossBoss catheter (BridgePoint Med-cal) or a knuckle wire technique (28–30). In the latterpproach, a looped, polymer-jacket wire (knuckle wire) isdvanced without rotation in the direction of the distalTO segment. Typically, the leading end of the knuckleire will be the stiff-to-floppy transition point near the

ibbon/coils of the guidewire. Although it may seem coun-erintuitive, this approach has been tested to be a much saferay to advance through the course of an ambiguous CTO

egment than with stiffer guidewires. The reason relates todventitial distensibility. Blunt objects can be accommo-ated within the adventitia without perforation. Stiff guide-ires, by contrast, may penetrate the adventitia becauseore force is directed to the relatively small area of the tip.

n addition, the knuckled wire is less likely to be directednto and subsequently perforate small branches. It is impor-ant to manage the size of the knuckle with a diameter thatatches the expected vessel size and ensure that it extends

ongitudinally within the vessel structure. This knuckle wire
echnique, or alternatively, the blunt-tipped CrossBoss
atheter (BridgePoint Medical) are effective ways to moveorward within the CTO segment when wire methods areonsidered inefficient or less safe. The CrossBoss catheteras the advantage of creating a smaller subadventitial space,hich is less likely to accumulate blood. Such features can

acilitate use of the Stingray system, as false lumen hema-oma may decrease vessel wall contact with the Stingrayalloon and wire and thus hinder re-entry attempts. Inddition, a dissection/hematoma that is too large canmpinge upon the true lumen, making re-entry moreifficult.

Re-entry techniques. After subintimal crossing, 2 primaryethods can be used for re-entering the lumen: 1) wire-

ased (LaST method) (31); or 2) device-based (Stingrayalloon and guidewire, BridgePoint Medical).

The LaST Method

When antegrade wiring fails and Stingray-based re-entry orretrograde techniques are not an option or have failed, andalternate bailout strategy is the LaST technique. Once amicrocatheter is positioned near the re-entry point, theknuckle wire is withdrawn and a stiff polymer jacket and/ora stiff tapered guidewire is inserted and directed into thedistal true lumen (31).

The Stingray System

The Stingray system (BridgePoint Medical) consists of aballoon that assumes a flat shape when inflated at 3 to 4atm, and a guidewire with an extreme 0.0025-inch tapereddistal tip (24,30). The Stingray balloon has 2 exit ports thatare diametrically opposed. Each port is proximal to aradio-opaque marker. The Stingray guidewire is advancedthrough the luminal exit port of the Stingray balloon untilthe wire crosses into the true lumen, which needs to beconfirmed by contralateral injection, or by visualizationthough ipsilateral collaterals (Fig. 3, Online Videos 6, 7, 8,9, 10, and 11). Sometimes the Stingray wire may fail toadvance into the distal true lumen despite effective re-entry,as it tends to catch tissue and re-exit in a false channel. Insuch cases, the Stingray wire should be exchanged for aplastic-jacket guidewire, which can be readvanced into thesame puncture hole created by the Stingray guidewire, andthen more easily positioned in the distal vessel. This latertechnique has emerged as a very effective and efficientvariant to avoid further damage to the distal vessel (“stickand switch” technique), especially when diseased and/ornegatively remodeled.

Retrograde Dissection Re-Entry

Reverse CART. The most commonly used method to con-nect the proximal and distal true lumen in retrograde CTO
PCI procedures if retrograde true lumen crossing attempts



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Figure 2. Complex Antegrade and Retrograde Intervention of a Right Coronary Artery CTO

Bilateral coronary angiography demonstrating a proximal right coronary artery chronic total occlusion (CTO) due to in-stent restenosis (arrow, A) (see OnlineVideo 1). The right posterior descending coronary artery filled by septal collaterals from the left anterior descending coronary artery (B) (see Online Video 2).Angiographic characteristics included defined proximal cap, good distal target, long lesion length, and appropriate retrograde “interventional collaterals.” Ante-grade crossing attempts using a CrossBoss catheter (BridgePoint Medical) (arrow, C) and antegrade wire escalation failed. A Corsair microcatheter (arrow, D)(see Online Video 3) was advanced retrograde via a septal collateral to the mid right coronary artery over a nontapered polymer-jacket guidewire, but attemptsto cross the occlusion retrograde failed (E). Repeat antegrade crossing attempts with a moderately stiff, nontapered polymer-jacket wire (Pilot 200 wire, AbbottVascular, Santa Clara, California) using limited subintimal tracking technique were successful in subintimal advancement of the wire (arrow, F) (see Online Video4). After a GuideLiner catheter (Vascular Solutions, Minneapolis, Minnesota) (arrowhead, G) was advanced into the proximal right coronary artery a ConfianzaPro 12 wire (Abbott Vascular) (arrow, G) successfully crossed the occlusion into the distal true lumen. After implantation of multiple drug-eluting stents anexcellent angiographic result was achieved (H) (see Online Video 5). This case highlights the importance of multiple modifications in the procedural plan (I), and“switching” strategies to be adaptive during chronic total occlusion percutaneous coronary interventions. LaST � limited antegrade subintimal tracking.

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are unsuccessful is the reverse CART (17,23,32) technique(Fig. 4, Online Videos 12, 13, 14, 15, 16, and 17). In thismethod, a microcatheter (often Corsair microcatheter,

Figure 3. Antegrade Crossing—Provisional Re-Entry

Coronary angiography demonstrating a chronic total occlusion of the mid leftteristics included well-visualized proximal cap, good distal target, and lesion lesota) was advanced to the proximal cap (arrow, B) (see Online Video 7). Withmid left anterior descending coronary artery (arrow, C) (see Online Video 8). T(arrows D) (see Online Video 9), located adjacent to the true lumen (arrowheinto the distal true lumen. Angiography after predilation showed (as expectedmultiple drug-eluting stents, an excellent angiographic result was achieved (G

Asahi Intecc) is placed across a collateral vessel from the

donor artery and into the CTO segment over a guidewire.An antegrade wire is advanced into the CTO segment aloneor in combination with a crossing catheter or a balloon. An

or descending artery (arrows, A) (see Online Video 6). Angiographic charac-�20 mm (H). A CrossBoss catheter (BridgePoint Medical, Plymouth, Minne-st spin technique, the catheter crossed the occlusion subintimally into theossBoss catheter was exchanged for a Stingray balloon (BridgePoint Medical)). A Stingray guidewire (arrow, E) (see Online Video 10) successfully crossedction at the area of subintimal crossing (arrows, F). After implantation ofOnline Video 11).

anteringththe fahe Crads, D) disse) (see

angioplasty balloon is approximated over the antegrade wire









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Figure 4. Primary Retrograde PCI to a Right Coronary Artery CTO

Dual coronary angiography demonstrating a chronic total occlusion (CTO) of the proximal right coronary artery (arrows, A and B) (see Online Videos 12 and 13)with distal filling via collaterals from the left anterior descending coronary artery. The angiographic characterization was poorly identified proximal cap, longlesion, diffusely diseased distal target, and good interventional collaterals (H). A Corsair microcatheter (Asahi Intecc, Nagoya, Japan) (arrow, C) (see Online Video14) was advanced retrogradely via a septal collateral over a polymer-jacket, nontapered guidewire, to the distal right coronary artery. A second Corsair micro-catheter (arrowhead, C) was advanced antegradely to the mid right coronary artery. After antegrade insertion of a GuideLiner catheter (Vascular Solutions, Min-neapolis, Minnesota) (arrowhead, D) (see Online Video 15), a 2.5 � 20-mm balloon was inflated over the antegrade guidewire in the mid right coronary artery(arrow, D), and reverse controlled antegrade and retrograde tracking and dissection was performed, followed by successful advancement of a retrogradePilot 200 guidewire (Abbott Vascular, Santa Clara, California) (E) (see Online Video 16) into the antegrade GuideLiner (arrowhead, E). A ViperWire Advance335-cm guidewire (Cardiovascular Systems, St. Paul, Minnesota) was externalized followed by pre-dilation of the right coronary artery (F) and implantation ofmultiple drug-eluting stents, restoring Thrombolysis In Myocardial Infarction flow grade 3 antegrade flow (G) (see Online Video 17). LaST � limited antegradesubintimal tracking; PCI � percutaneous coronary intervention.








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adjacent to the retrograde microcatheter and inflated. Be-fore this, the antegrade and retrograde systems may reside inthe same subadventitial space, within the CTO plaque, or incombination. However, if both systems are within theessel structure, relative locations become less materialecause balloon angioplasty creates a connection betweenhe 2 spaces. A retrograde wire can then be passed intohe proximal vessel, and wire externalization (whichnvolves externalizing the tip of a long, 300-cm or moreuidewire at the antegrade hemostatic valve) or retro-rade balloon angioplasty can be performed. The Viper-

ire Advance guidewire (CSI, St. Paul, Minnesota) is35 cm long, provides excellent support, and is currentlyhe preferred wire for externalization (32,33) wherevailable. Intravascular ultrasonography guidance can fa-ilitate performance of reverse CART, by allowing selec-ion of the appropriate balloon size (34). In certainircumstances, the classic CART technique can be per-ormed with retrograde dilation with a Corsair catheterr OTW balloon and advancement of an antegrade wireo the distal true lumen. We recently published detailedractical descriptions of the retrograde technique (32,33).

onclusions

The presented procedural algorithm can provide a usefulworking and training framework for operators perform-ing CTO PCI and may help increase attempt and successrates, improve efficiency, and minimize complications.Further studies are needed to validate this approach.

AcknowledgmentsThe authors would like to acknowledge the tremendousassistance of Todd Tourand, Nancy Morris, and ChadHarshman-Smith in preparing Table 1.

Reprint requests and correspondence: Dr. Emmanouil S. Brila-kis, Dallas VA Medical Center (111A), 4500 South LancasterRoad, Dallas, Texas 75216. E-mail: [email protected].

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18. Di Mario C, Ramasami N. Techniques to enhance guide cathetersupport. Catheter Cardiovasc Interv 2008;72:505–12.

19. Mahmood A, Banerjee S, Brilakis ES. Applications of the distalanchoring technique in coronary and peripheral interventions. J Inva-sive Cardiol 2011;23:291–4.

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23. Tsuchikane E, Katoh O, Kimura M, Nasu K, Kinoshita Y, Suzuki T.The first clinical experience with a novel catheter for collateral channeltracking in retrograde approach for chronic coronary total occlusions.J Am Coll Cardiol Intv 2010;3:165–71.

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26. Ben-Gal Y, Weisz G, Collins MB, et al. Dual catheter technique forthe treatment of severe coronary artery perforations. Catheter Cardio-vasc Interv 2010;75:708–12.

27. Chambers CE, Fetterly KA, Holzer R, et al. Radiation safety programfor the cardiac catheterization laboratory. Catheter Cardiovasc Interv2011;77:546–56.

28. Colombo A, Mikhail GW, Michev I, et al. Treating chronic totalocclusions using subintimal tracking and reentry: the STAR technique.Catheter Cardiovasc Interv 2005;64:407–11, discussion 412.

29. Galassi AR, Tomasello SD, Costanzo L, et al. Mini-STAR as bail-outstrategy for percutaneous coronary intervention of chronic total occlu-sion. Catheter Cardiovasc Interv 2012;79:30–40.

30. Brilakis ES, Badhey N, Banerjee S. “Bilateral knuckle” technique andStingray re-entry system for retrograde chronic total occlusion inter-vention. J Invasive Cardiol 2011;23:E37–9.

31. Lombardi WL, Retrograde PCI: what will they think of next?

32. Brilakis ES, Grantham JA, Thompson CA, et al. The retrogradeapproach to coronary artery chronic total occlusions: a practical ap-proach. Catheter Cardiovasc Interv 2012;79:3–19.

33. Joyal D, Thompson CA, Grantham JA, Buller CEH, Rinfret S. Theretrograde technique for recanalization of chronic total occlusions: astep-by-step approach. J Am Coll Cardiol Intv 2012;5:1–11.

34. Rathore S, Katoh O, Tuschikane E, Oida A, Suzuki T, Takase S. Anovel modification of the retrograde approach for the recanalization ofchronic total occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking. J Am CollCardiol Intv 2010;3:155–64.

Key Words: chronic total occlusion � devices � percuta-neous coronary intervention.

APPENDIX

J Invasive Cardiol 2009;21:543. For accompanying videos, please see the online version of this article.

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